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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure at the time of admission residents had physician orders [REDACTED].#473) reviewed. Specifically, Resident #473's hospital discharge orders and hospital discharge summary had conflicting diet consistency information that was not clarified on admission to the facility. Findings include: The facility policy, Physician Visits & Medical Orders, revised 1/19/2024, documented the attending physician would prescribe the medical regimen of care for the residents they admitted . Before or on admission of a resident, the physician would submit information pertaining to the admitting [DIAGNOSES REDACTED]. Medical orders would be written by physicians to meet the needs of the resident. Members of the interdisciplinary team would provide care, services and treatment according to the most recent medical orders and according to laws, regulations and standards of practice. The facility policy, Admission of Resident to Care Facility, revised 1/19/2024, documented the facility would ensure each resident received necessary care and services upon admission. Resident #473 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment was not yet completed. The 1/21/2025 hospital discharge summary documented the hospital stay was complicated by new thin liquid dysphagia (difficulty swallowing), for which the resident was given a thickened liquid diet. The resident never had trouble with thin liquids or swallowing at baseline per family. The speech language pathologist evaluation during admission showed evidence of dysphagia with thin liquids. The discharge summary documented diet as below, can be re-evaluated by speech language pathologist. The nursing home transfer documented a regular diet. The 1/21/2025 physician order [REDACTED]. The order was signed by Nurse Practitioner #23 on 1/21/ 2025. During a lunch observation on 1/22/2025 at 12:41 PM, Resident #473 had a mug containing a thin brown liquid and a cup containing a thin, clear amber colored liquid. The resident was actively drinking the amber colored liquid. The resident's visitor questioned the liquids as the resident had thickened liquids the day before. A speech language pathologist arrived and removed the thin fluids and said they were going to check with the other speech language pathologist to see if they did an evaluation on 1/21/ 2025. The 1/22/2025 at 12:52 PM Physician #7 order documented the resident was to receive a regular diet, regular texture, with nectar consistency liquids. The 1/22/2025 at 2:24 PM Speech Language Pathologist #16 progress note documented a skilled dysphagia evaluation was medically indicated due to discrepancy between diet recommendation on the hospital discharge paperwork and report from the resident's family. Thin liquids were not trialed due to patient preference for nectar. They recommended regular solids, nectar liquids, and skilled dysphagia treatment 3-5 times a week for 4 weeks using restorative and compensatory techniques. During an interview on 1/23/2025 at 1:36 PM, Licensed Practical Nurse Manager #15 stated when admitting a resident, the Director of Admissions brought them a hard copy of the hospital orders. They entered those orders into the electronic medical record. The Director of Nursing and another Nurse Manager checked the orders for accuracy. That was their triple check system. If information in the discharge paperwork was inconsistent, it should be clarified. They were not working the day Resident #473 was admitted so they had not reviewed their orders. The resident was admitted on thin liquids and should have been on nectar thick. The correct consistency was important because the resident could have choked or aspirated which could lead to complications. During an interview on 1/24/2025 at 9:10 AM, the Director of Admissions stated when a resident was admitted they received the discharge summary and orders the day of admission, reviewed them, and uploaded them to the documents tab in the electronic medical record. If the hospital orders and discharge summary had conflicting information, they would clarify. Additionally, they created a portable document format (PDF) file with all preadmission information they had obtained and sent it to the on-call provider, the Director of Nursing and the appropriate Nurse Manager. The on-call provider, once they received the portable document format, printed it, signed it, and returned it and those became the admission orders [REDACTED]. As a result, it did not flow into the orders. Therefore the 1/16/2025 order for a regular diet was the only active hospital diet order the resident had. They became aware of that issue after the resident was already admitted and the question regarding the appropriate liquid consistency was raised. The resident's admission paperwork did not give them an inclination there was a swallowing issue and when they saw the regular diet, it did not cue them to look for dysphagia. They did not think their facility caught the issue but should have as that was why there was a triple check system. During an interview on 1/24/2025 at 10:03 AM, Speech Language Pathologist #16 stated they reviewed Resident #473's records and saw a regular diet but did not see the resident had thin liquid dysphagia. On 1/21/2025, they were told the resident's family wanted the resident to have nectar thick liquids, so they did an evaluation that day. During an interview on 1/24/2025 at 11:21 AM, the Director of Nursing stated they often put the admissions orders in and if not, they performed one of the checks. When they put the orders in the electronic medical record, they looked at the discharge orders but only looked at the discharge summary if there were new medications. Any order that needed clarification was not activated. They entered Resident #473's admission orders [REDACTED]. They had since reviewed the discharge summary and saw the resident had thin liquid dysphagia while at the hospital. If they had reviewed the discharge summary on admission and saw that, they would have asked speech to evaluate the resident and held the diet order pending that evaluation to make sure they could swallow safely. During an interview on 1/24/2025 at 11:44 AM, Nurse Practitioner #23 stated when there was a new admission, they looked over the discharge orders and discharge summary to make sure everything was appropriate. Once nursing entered the orders, they reviewed and signed off. If there was conflicting information, they would ask the nursing staff to ask for clarification from the discharging facility. They were involved in Resident #473's admission and would have reviewed their orders and summary. They did not know if there was conflicting information about their diet and did not recall asking nursing to clarify their diet. During a follow up interview on 1/24/2025 at 2:49 PM, Nurse Practitioner #23 accessed the resident's medical record and reviewed the discharge instructions and summary. They stated they saw the diet was regular but in the discharge summary, saw documentation on evidence of dysphagia and had to be reevaluated by speech. They stated the information was certainly conflicting and orders should have been clarified to ensure they were given the appropriate fluids to reduce the risk of aspirating. 10 NYCRR 415. 11 | Plan of Correction: ApprovedFebruary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident identified as #473 diet order was corrected immediately. Resident #473 has since been discharged to a lower level of care. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All new admissions from the previous three months discharge summaries, and physician orders [REDACTED]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The policy medication physicians orders management has been updated to include reconciliation of hospital discharge orders with the discharge summary and discrepancies to be clarified by physician order. All nursing staff will be educated on policy revisions and changes. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice A weekly audit of the reconciliations will be completed for three months. Followed by monthly for three months and quarterly for six months. All audit results will be reported at QAPI. The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care; a Level II Preadmission Screening and Resident Review identifies the specialized services required by the resident) for 1 of 2 residents (Resident #66) reviewed. Specifically, Resident #66 had a significant mental illness and a change in behavior that required medication intervention and there was no documentation a new Screen Level I was completed, or a Level II referral was initiated. Findings include: The New York State Department of Health Instruction Manual for Department of Health-695 (2/2009) documented if a Residential Health Care Facility resident was newly diagnosed with [REDACTED]. If a Residential Health Care Facility resident, who was previously identified as having mental illness was identified as having experienced a significant change in physical and/or mental condition, a new SCREEN and Level II Evaluation must be completed within 14 calendar days. During an interview on 1/23/2025 at 11:16 AM, the Administrator stated they did not have a facility policy regarding Preadmission Screening and Resident Review. Resident #66 had [DIAGNOSES REDACTED]. The 12/26/2024 Minimum Data Set assessment documented the resident was cognitively intact, had a [DIAGNOSES REDACTED]. The comprehensive care plan initiated on 5/1/2024, and revised 8/7/2024, documented the resident had a psychosocial well-being problem related to the [DIAGNOSES REDACTED]., fluids, and feces; they had made accusations of rape within the facility, did not trust staff or their family, and continued to confabulate incidents of abuse. Interventions included monitor/document resident feelings and response to internal and external problems, initiate referrals as needed or increase social relationships, allow time to answer questions and to verbalize feelings, remove to a calm safe environment when conflict arises, and paper and plastic products for safety during meals. The comprehensive care plan initiated on 10/18/2021, and revised 1/19/2025, documented the resident had potential for non-compliance related to impaired judgement with incontinence care, showers, medication, and activities of daily living. Interventions included allow time for making decisions about treatment regime to provide sense of control, encourage participation, reapproach if resistant with activities of daily living, and to praise the resident when behavior was appropriate. The 4/9/2021 Screen Form (New York State Department of Health-695 2/2009) documented the resident required skilled services, did not have a significant mental illness, and did not require a Level II evaluation. The resident's face sheet documented the resident's [MEDICAL CONDITION] and major [MEDICAL CONDITION] [DIAGNOSES REDACTED]. 2023. Nursing notes from 10/28/2024-11/4/2024 documented the resident had behavioral symptoms including refusal of medications, using profane language, hallucination, delusional thoughts, yelling and screaming, ripping the call light from the wall, verbally abusing staff, throwing food, and stating staff were mental patients making them watch them sexually assault and murder people. The 10/21/2024 Psychiatric Mental Health Nurse Practitioner #44 progress note documented a chief complaint of irritability and delusions. The resident was being seen after addition of Secuado (a medication used to treat [MEDICAL CONDITION]) for management of [MEDICAL CONDITION], irritable behaviors, and mood stabilization. The resident stated they were a brain surgeon in one of their other lives. The resident was [DIAGNOSES REDACTED]. The plan/recommendations were given that the resident recently recovered form COVID-19 infection which may have influenced their behaviors. The 10/30/2024 Social Worker #38 progress note documented the interdisciplinary team met for the resident's quarterly care meeting. The resident had been exhibiting more aggressive behaviors toward staff and refusing medications over the last two weeks. The resident continued to see the psychiatric nurse practitioner for medication reviews and a psychotherapist a few times. However, the resident had been refusing to see the psychotherapist the last couple of months. The resident was alert, oriented, and able to make their needs known. However, due to the resident's [MEDICAL CONDITION] the resident often was non-compliant with care and medications. The 11/4/2024 Psychiatric Mental Health Nurse Practitioner #45 progress note documented they were asked by staff to see the resident who was non-compliant with their Secuado patch, was aggressive, yelling all night about having a baby, cursing staff, calling them (expletive), throwing food and drink at staff, and attempting to rip the call bell out of the wall. They approached the resident in the company of two staff members and the resident yelled Get out!. The resident was at the maximum dose of [MEDICATION NAME] (antipsychotic), but it seemed ineffective in managing the [MEDICAL CONDITION]. The resident's behaviors posed an immediate risk to the resident or others. Nonpharmacological interventions and least restrictive measures had been attempted in the past with minimal improvement. During an interview on 1/23/25 at 12:15 PM Social Worker #18 (from a sister facility) stated if a resident had a significant change with mental illness it needed to be reviewed. Resident #66 did not have a Level II screen, and they had questioned that due to the resident's mental illness diagnoses. The resident was diagnosed with [REDACTED]. They now had escalation of behaviors requiring medication intervention: The resident should have had a new screen. If they did not have a new Level II screen, they would not know what specialized services the resident required and was placed in long term care appropriately. Resident #66 may need alternative services due to their long standing history of [MEDICAL CONDITION]. During an interview 1/23/25 01:21 PM the Administrator stated the Director of Social Work was responsible for maintaining Preadmission Screening and Resident Review, referring and updating the state authority. 10NYCRR 415. 11(e) | Plan of Correction: ApprovedFebruary 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices Identified resident #66 will be screened and referred for a level II PASARR How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken A 100% audit of all current residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions will be referred for a level II PASARR. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Education will be provided to the Director of Admissions and Social Work department on level II PASARR requirements How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice A monthly audit of all admissions and newly diagnosed serious mental disorders will be completed to ensure level II PASARR is completed. Audit results will be reported to QAPI monthly The date for correction and the title of the person responsible for correction of each deficiency Director of Social Work |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that residents who required [MEDICAL TREATMENT] services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #65) reviewed. Specifically, Resident #65 received [MEDICAL TREATMENT] treatments at a community-based [MEDICAL TREATMENT] center and there was inconsistent communication and collaboration between the [MEDICAL TREATMENT] center and the facility. The facility policy, Care of [MEDICAL TREATMENT] Resident, revised 3/30/2024, documented all residents receiving [MEDICAL TREATMENT]-[MEDICAL TREATMENT] would have interventions in place for appropriate care and treatment. The facility would complete the [MEDICAL TREATMENT] report prior to each [MEDICAL TREATMENT] treatment and send it to the [MEDICAL TREATMENT] center with the resident. The [MEDICAL TREATMENT] reports would be reviewed upon the resident's return from [MEDICAL TREATMENT] and confirm any new recommendations with the primary physician, if indicated. Resident #65 had [DIAGNOSES REDACTED]. The 12/19/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with most activities of daily living, and received [MEDICAL TREATMENT]. The Comprehensive Care Plan, revised 7/22/2024, documented the resident required [MEDICAL TREATMENT]. Interventions included [MEDICAL TREATMENT] three times a week and obtain vitals and weights per recommendations. The 8/19/2024 physician orders [REDACTED]. - [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. - vital signs before and after [MEDICAL TREATMENT] treatments. Document pre and post weight obtained at [MEDICAL TREATMENT] and call [MEDICAL TREATMENT] if not listed in the communication book. - the resident's [MEDICAL TREATMENT] communication book was to be filled out and sent with the resident to [MEDICAL TREATMENT], reviewed upon return from [MEDICAL TREATMENT], and call the [MEDICAL TREATMENT] provider for report if communication book was not present on return from [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. Resident #65's [MEDICAL TREATMENT] report sheets for 34 [MEDICAL TREATMENT] sessions had 25 sessions with incomplete documentation of vital signs and/or pre and post [MEDICAL TREATMENT] weights from the [MEDICAL TREATMENT] center staff on 10/29/2024, 10/31/2024, 11/2/2024, 11/7/2024, 11/9/2024, 11/12/2024, 11/14/2024, 11/19/2024, 11/21/2024, 11/27/2024, 11/30/2024, 12/3/2024, 12/5/2024, 12/7/2024, 12/10/2024, 12/12/2024, 12/14/2024, 12/18/2024, 12/21/2024, 12/23/2024, 12/26/2024, 12/28/2024, 12/30/2024, 1/9/2025, 1/18/2025, and 1/21/ 2025. The interdisciplinary progress notes did not document any communication with the [MEDICAL TREATMENT] center regarding any follow up that had been done regarding the 25 incomplete [MEDICAL TREATMENT] report sheets. During an interview on 1/16/2025 at 1:09 PM, Resident #65 stated they received [MEDICAL TREATMENT] three times a week for about 4 hours each time. They carried the communication book back and forth between the two facilities. During an interview on 1/21/2025 at 3:04 PM, Licensed Practical Nurse #10 stated when a resident returned from [MEDICAL TREATMENT] their vital signs and dressing were checked. The nurse that was assigned to the resident's hall was responsible for checking the communication sheet upon the resident's return. If the sheet was blank, they should call the [MEDICAL TREATMENT] center to see if there was a concern and document they did so. They stated they did not look at Resident #65's report sheet when the resident returned from [MEDICAL TREATMENT] that day or call [MEDICAL TREATMENT] to get a report. It was important to get a report from [MEDICAL TREATMENT] to see if the resident had a full treatment and to know if their blood pressure dropped. During an interview on 1/23/2025 at 12:13 PM, Licensed Practical Nurse Manager #15 stated Resident #65 had a communication book that went with them to [MEDICAL TREATMENT]. Their unit was responsible for completing the upper portion and the [MEDICAL TREATMENT] center was responsible for the lower section. There was no phone-to-phone report between the two facilities. They expected when a resident returned from [MEDICAL TREATMENT], the nurses review the sheet to make sure the vital signs were good. If the lower section was not filled out, vital signs would be taken right then, the [MEDICAL TREATMENT] center was called to get report, and all communication would be documented in a progress note. That process was important so that anyone could go back and look at those sheets and know what the vital signs were and if [MEDICAL TREATMENT] went well. During an interview on 1/24/2025 at 11:10 AM, the Director of Nursing stated prior to going to [MEDICAL TREATMENT] Resident #65 received a few medications, had their vital signs taken, and the communication book was sent with them. [MEDICAL TREATMENT] should fill out their section and nursing should look at the report sheet when the resident returned. It was hit and miss if [MEDICAL TREATMENT] completed the form. They expected to be notified if there were any issues on the form. If the form was blank or incomplete nursing should be checking the resident's vital signs and notify either them or the Unit Manager so they could see the resident and make sure they were stable. Incomplete report sheets were a normal, ongoing thing. [MEDICAL TREATMENT] was good about calling them if there was an issue. If there were no issues, they might not see anything on the report sheet. If [MEDICAL TREATMENT] did not call and the form was blank, they assumed everything was fine. 10NYCRR 415. 12(k) | Plan of Correction: ApprovedFebruary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident identified as #65 continues on [MEDICAL TREATMENT] treatment. Resident #65s order for the [MEDICAL TREATMENT] communication book to be returned and completed and advised to contact [MEDICAL TREATMENT] office directly if incomplete. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken Currently no other residents require [MEDICAL TREATMENT]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur LPN and RN staff to be educated on [MEDICAL TREATMENT] policy. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice An audit to monitor [MEDICAL TREATMENT] communication book will be completed weekly for three months, monthly for three months and quarterly for six months and reported to QAPI. The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure a discharge planning process was in place addressing each resident's discharge goals and needs and involved the resident and the resident representative for 1 of 2 residents (Resident #105) reviewed. Specifically, Resident #105 expressed the goal to be discharged back to their prior living situation and was not assisted with discharge planning or updates on the status of their discharge goal. Findings include: The facility policy Comprehensive Care Plan, revised 1/19/2024, documented to the extent practicable, the resident had the right to participate in planning for care, treatment and services shall include discharge planning to include return to the community or discharge to an appropriate level of care. The facility policy, Discharge Planning, revised 8/23/2023, documented the facility would work collaboratively with the resident to ensure a smooth transition of care; would ensure all residents who expressed a desire to return to the community were provided the opportunity and assistance by the facility to allow the resident to live in the most integrated and least restrictive setting possible; resident education would be a major focus of discharge planning activities; and would permit the resident, their legal representative or health care agent the opportunity to participate in deciding where the resident will live after discharge from the facility; and permit the resident, their legal representative or health care agent the opportunity to participate in deciding where the Resident #105 had [DIAGNOSES REDACTED]. The 11/15/2024 Minimum Data Set admission assessment documented the resident's overall discharge goal was to be discharged to the community and an active discharge plan was already occurring for the resident to return to the community. The 12/27/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and was independent with most activities of daily living. The Comprehensive Care Plan revised 11/18/2024, documented the resident had a discharge plan to complete short term rehabilitation and return to their apartment if able. Interventions included inform the resident about referrals made to support the discharge and organize discharge meetings as needed. The 11/8/2024 at 1:42 PM former Social Worker #38 's progress note documented Resident #32 presented as alert and oriented, was able to make their own decisions and make their needs known. The resident stated their goal was to attend and participate in therapy to regain strength and independence and go back to their apartment where they lived independently. The resident had a friend who checked on them and assisted with their needs. The resident stated they were able to manage their own activities of daily living and was still driving to get their groceries. The 11/12/2024 at 9:22 AM former Social Worker #38 's progress note documented per the hospital record; the resident's friend was unsure if the resident would be able to return to their apartment. Social Worker #38 would call the friend to schedule a care meeting per the resident's wishes. The 12/27/2024 Occupational Therapy Discharge Summary documented the resident was independent for all functional skills except bathing which required set up assistance. The 12/27/2024 Physical Therapy Discharge Summary documented the resident was independent for all functional skills. There was no documented evidence an Interdisciplinary care plan meeting was held to discuss the resident's discharge potential and goals. During an interview on 1/16/2025 at 11:20 AM, Resident #105 stated they were concerned about not being able to go home. They were supposed to go home in 12/ 2024. They worked with Veterans Affairs for everything they needed. They had not received therapy for the last two weeks and had to postpone several appointments because of still being at the facility. They had friends that could give them a ride home and had practiced stairs in therapy. They were still paying for their apartment and their landlord lived downstairs. They did not recall attending any care plan or discharge meetings since being admitted . During an interview on 1/22/2025 at 4:43 PM, Certified Nurse Aide #20 stated Resident #32 was very independent, was steady on their feet, and alert and oriented. During an interview on1/22/2025 at 4:47 PM, Licensed Practical Nurse #21 stated Resident #32 was independent, alert and oriented, pleasant, had good safety judgement and was able to make their needs known. They were not sure why they were still in the facility. During an interview on 1/23/2025 at 12:57 PM, Licensed Practical Nurse Manager #15 stated Resident #32 was at the facility for rehabilitation and their plan was to go home. The resident was very independent, quiet, liked to stay in their room, and their cognition was good. They did not recall going to the resident's care plan meeting or any discussion about a discharge plan for them. They were not sure if the resident was still receiving therapy or why they were still at the facility. The facility's goal was to get people home as quickly as possible. During an interview on 01/23/2025 at 2:34 PM, the Occupational Director stated Resident #32 came to them due to a fall at home. The resident was no longer on therapy services and had maxed out about a month ago. They were mostly independent for activities of daily living. The Occupational Director believed the resident was on a wait list at a senior apartment complex downtown and the apartment they lived in prior was a concern due to it being a bedroom in someone else's house. Once the resident was accepted at the senior apartment complex, they would plan for home services to make sure it was set up well for them. The resident would need daily checks and a life alert due to high risk for falls. If someone had been independent for a couple weeks and not a fall risk, they would be a candidate for discharge. During an interview on 1/23/2025 at 3:05 PM, Social Worker #18 stated the Licensed Practical Nurse Director of Quality Management scheduled the discharge planning meetings and resident progress and goals were discussed. Residents should be invited to all care plan meetings without exception and there should be documentation of who attended the care plan meeting. Social work entered the discharge care plan and when they became aware that a resident was going to be cut from therapy they started working on the discharge plan. Resident #32's goal was to return to their apartment, and they did not know if the resident was on a wait list to go to a senior apartment complex. The resident was cut from therapy on 12/27/2024 and should have had things put in motion at that time to get them discharged . There was no documentation of any meetings or communication with the resident about going home. The resident slipped through the cracks. It was important for the mental health of the resident to go home and not lose their functionality while waiting to do so. During an interview on 1/23/2025 at 4:07PM, the Licensed Practical Nurse Director of Quality Management stated they or the Administrator scheduled the discharge planning meetings and let the family and resident know. They called or spoke directly to the families and told the residents directly and the conversations should be documented. They stated they were not involved with Resident #32, had no firsthand knowledge of the resident, was not involved in a discharge care plan meeting. Former Social Worker #38 had been talking with the resident. The resident was cut from therapy on 12/27/2024 which should have triggered a care plan meeting. During an interview on 1/24/2025 at 8:44 AM, the Administrator stated they knew the resident was on a waiting list for a senior apartment complex, was no longer getting therapy, and was independent/supervision for activities of daily living. They thought there was some question regarding the resident's cogn | Plan of Correction: ApprovedFebruary 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident #105 has met with the Social work department and a discharge plan is being developed with the residents input as well as the IDT. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken A 100% audit of all residents wishing to discharge for an active discharge plan will be completed. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur IDT will be educated on the discharge planning policy and procedure. A discharge planning meeting will be scheduled upon admission. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice An audit will be conducted by the MDS Coordinator or representative assigned to confirm discharge planning meeting has occurred by the completion of the comprehensive MDS. The date for correction and the title of the person responsible for correction of each deficiency MDS Coordinator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, there were unclean areas in the kitchen; and potentially hazardous foods in the main kitchen were prepared and left out of temperature too long. Findings include: The facility policy, Cooling of Food Items, effective 8/5/2021, documented foods should be cooled 135 degrees Fahrenheit to 70 degrees Fahrenheit in 2 hours and from 70 degrees Fahrenheit to 41 degrees Fahrenheit in 4 hours (not to exceed 6 hours). If food is not cooled to 41 degrees Fahrenheit within 6 hours, reheat to 165 degrees Fahrenheit for at least 15 seconds (within 2 hours) and discard if not served immediately. Place pans in an ice bath and stir foods as they cool, then refrigerate. Place cooling items on the top shelf of the refrigerator or freezer uncovered or loosely covered in 2-inch shallow pans. The facility policy, Food Storage, last revised 7/6/2023, documented all perishable foods would be stored at proper temperatures, and refrigerated at 35-41 degrees Fahrenheit. During an observation on 1/16/25 at 10:55 AM the drain behind the oven was full and backing up with a strong, foul odor present. There was food debris under and around the equipment. During an observation on 1/16/25 at 10:59 AM a deep hotel pan of crab cake mix in the continental 2 door cooler was labeled as made 1/15. The crab cake mix was measured at 48 degrees Fahrenheit in the presence of the Director of Dietary. They stated food could be out of temperature for 2 hours and the mix was made the previous day by the night cook. They stated the drain had been a problem on and off. The Crab Cake production recipe documented once the crab cakes were portioned after mixing, chill the crab cakes for 2-3 hours. Cover product and marinate at or below 40 degrees Fahrenheit. During an interview on 1/16/25 at 11:05 AM the Facility Services Director stated they had a problem with the drain in the kitchen about 3 or 4 months ago and had the contractor come and snake it. During an interview on 1/17/25 at 2:22 PM the Director of Dietary stated cooling of food should not be done in quantity. They documented cooling temperatures of items like roasts. They prepared a lot of food the day before it was served, and they made sure it was completely chilled before service. They stated when using warm ingredients, such as the crab cake mix, it should have been put into shallow pans and chilled faster. During an interview on 1/16/25 at 2:30 PM Cook #43 stated they prepared the crab mix the previous evening mix using cold crab, eggs, heavy cream, and mayonnaise and breadcrumbs at room temperature. They placed it in the hotel pan and into the cooler. They stated they should have split the crab mix into shallower pans. Food could be out of temperature for 4 hours. During an interview on 1/17/25 at 2:51 PM Registered Dietitian #34 stated it was important to ensure foods were properly prepared, cooled, and stored to reduce the risk of any bacterial pathogenic growth and reduce the risk of food borne illness. 10NYCRR 415. 14(h) | Plan of Correction: ApprovedFebruary 28, 2025 F812 D What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Food identified was discarded immediately. The drain behind the oven was immediately reported to the Facility Services Director. The drain was unclogged and cleaned immediately as well as the food debris under and around the equipment were cleaned immediately. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken Additional food items were checked for appropriate temperature. No other drains were identified with a similar issue. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur PM cook #43 was provided education on 1/16/25 on policy Cooling of food items. All cooks were inserviced on the policy and procedure of cooling food items on 1/27/ 25. All dietary staff were inserviced on food storage policy and procedure on 2/6/ 25. Under all equipment cleaning will be added to the cooks daily cleaning schedule. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Dietary Manager or designee will audit all food items in the cooler and the cooling log three times a week for three months, weekly for three months and quarterly thereafter. Drains will change from a monthly cleaning rotation to weekly cleaning and/or as needed. 2 audits a week will be conducted to confirm no food debris is under or around equipment. All audits will be reported and reviewed at monthly QAPI meetings. The date for correction and the title of the person responsible for correction of each deficiency Dietary Manager |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated (NY 003) surveys conducted 1/16/2025-1/24/2025, the facility failed to ensure the residents' environment remained free of accident hazards for one (1) of three (3) residents (Resident #171) reviewed. Specifically, Resident #171 had a physician order [REDACTED]. This resulted in Immediate Jeopardy past non-compliance to Resident #171 and placed all residents on modified consistency diets at risk for serious injury, serious harm, serious impairment, or death. Findings include: The facility policy, Dysphagia, dated 3/2022 documented the Speech Language Pathologist would identify and convey swallowing recommendations to nursing and dietary staff so the recommendations could reflect on the resident's meal ticket. The care plan, orders, and care card were to be updated. The facility policy Activities of Daily Living Services revised/reviewed 1/19/2024, documented assistance with eating and drinking was provided to residents and included monitoring dietary restrictions. Regular training sessions were conducted to update staff on best practices and address identified areas for improvement. The 2019 Becky Dorner Diet and Nutrition Care Manual documented vegetables on a pureed diet should be soft, well-cooked, and pureed using appropriate recipes, and free from chunks, lumps, and/or seeds. All pureed foods were the consistency of moist mashed potatoes or puddings. Resident #171 had [DIAGNOSES REDACTED]. The 3/30/2024 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, had functional limitation in both arms and legs, was dependent for eating, did not have a swallowing disorder , and received a mechanically altered diet. The 1/29/2022 physician order [REDACTED]. The 11/29/2023 Speech Language Pathologist #35 evaluation and plan of treatment documented the resident had swallowing dysfunction and was referred for dysphagia services due to worsening signs/symptoms of dysphagia. The resident was on a pureed diet and aspiration (inhaling food/fluid into the lungs) precautions. The 4/4/2024 Registered Dietitian #34 quarterly nutritional assessment documented the resident had an abnormal weight loss, received a pureed diet with honey thickened liquids, a change in feeding ability was noted, and a mechanically altered diet was required. The Comprehensive Care Plan initiated 7/12/2023 and revised 4/25/2024 documented the resident had nutritional problems related to dysphagia and a mechanically altered diet, with a goal to tolerate consistency served with no episodes of aspiration. Interventions included monitor for signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and appearing concerned during meals; provide and serve regular pureed diet with honey thick liquids. The resident required assistance with activities of daily living. Interventions included extensive assistance of 1 with feeding, pureed solids with honey thick fluids. The 5/1/2024 facility Investigation Summary initiated by the Director of Nursing at 6:00 PM, documented Licensed Practical Nurse #10 reported Resident #171 was fed the wrong consistency diet at 5:30 PM in the 2nd floor dining room. The physician was notified, and the resident was sent to the emergency department. The investigation summary included the following witness statements: - 5/1/2024 Certified Nurse Aide #3 documented they were feeding the resident, noticed the resident was not swallowing, was trying to cough, and nodded their head when asked if they were choking. They sat the resident upright and began to take food out of their mouth. Another certified nurse aide (unidentified) told Certified Nurse Aide #3 the resident had the wrong consistency food, and the nurse was called. The statement did not include what food the certified nurse aide was feeding the resident. - 5/1/2024 Certified Nurse Aide #9 documented they entered the dining room, staff were already with the resident, they looked at the resident's meal tray, noticed it was the wrong consistency, took the tray to Dietary Aide #4 and explained that it was the wrong consistency. - 5/1/2024 Licensed Practical Nurse #10 documented they were called to the unit dining room for a coughing resident. Resident #171 had coughed up some food with a large amount of phlegm. Staff were unable to get the resident's blood oxygen saturation above 87%, the on-call provider was called, and the resident was sent to the emergency room . - 5/1/2024 Dietary Aide #4 was interviewed by the Director of Nursing and stated they did not remember the incident but believed the certified nurse aide must have served the wrong food. - 5/2/2024 Dietary Aide #13 documented they helped Dietary Aide #4 load the food cart to be taken to the 2nd floor unit for supper. Dietary Aide #13 told Dietary Aide #4 what each food item was, what scoop to use, and the tops of the pans were labeled with what each food item was. - on 5/2/2024 the Administrator reviewed video surveillance of the 2nd floor dining room. At 5:12 PM Certified Nurse Aide #3 brought Resident #171 their meal tray and began assisting the resident with feeding. Within minutes the resident began to show signs of choking. Multiple certified nurse aides and a nurse stepped in to confirm the resident's airway was clear and no longer choking. There was no [MEDICATION NAME] Maneuver performed and the resident was able to cough up the food consumed. The video review did not include observations of the resident's food being plated by dietary staff. - 5/3/2024 the Director of Nursing documented significant information related to the incident included Resident#171's meal ticket for 5/1/2024 was accurate, and the meal tray was accurate except for Brussels sprouts that were chopped, mechanical soft and not pureed. - The investigation summary submitted to the New York State Department of Health on 5/7/2024 at 1:16 PM by the Director of Nursing documented the dietary server (unidentified) filled the tray, the certified nurse aide (unidentified) passed out the tray and fed the resident. The dietary and certified nurse aide were suspended for 3 days. All nursing, social work, therapy, and recreation staff were educated and quizzed on safe dining. Certified Nurse Aide #3's educational record documented: - on 10/12/2023 they completed a Food Safety and Diets quiz. The quiz documented they were to never give any resident food or beverage unless they knew the resident's diet order and to report any concerns involving resident's safety and wellbeing. - on 10/19/2023, they completed the skill of feeding a resident which included tray placement/removal, diet types/consistencies, and reading meal ticket/documentation. The 5/2/2024 hospital discharge summary for Resident #171 documented the resident was admitted with breathing issues due to aspiration of Brussels sprouts. The discharge [DIAGNOSES REDACTED]. A 5/3/2024 at 4:17 PM Director of Nursing progress note documented the Interdisciplinary Team met to discuss the choking incident, an investigation was underway, dietary and nursing staff involved were to be re-educated, and leadership staff would spend time in the dining room at meals to monitor that meal tickets were being accurately filled. The 5/3/2024-5/14/2024 dietary consistency in-service documented dietary staff were educated on types and examples of appropriate diet consistencies and what foods to avoid for that type of consistency. A 5/14/2024 at 1:17 PM Director of Nursing progress note documented dining safety education went out to employees in dep | Plan of Correction: ApprovedFebruary 17, 2025 No plan of correction needed. IDR submitted 2/17/25 at 2:37pm |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure medication rates were not greater than 5 percent for 2 of 5 residents (Resident #27 and 110) reviewed. Specifically, Resident #27 was administered 5 medications over one hour late; their sliding scale insulin dose was given after breakfast and not before as ordered; and the insulin pen was not primed (removal of air bubbles); and Resident #110 was administered four medications via mouth and not via a gastrostomy tube as ordered and the medications were administered over one hour late. The facility's medication error rate was 37. 04%. Findings include: The facility policy, Medication Administration, revised 9/2029, documented the individual administering a medication would be aware of the route, frequency, and appropriate timing of medication administration. Any errors in medication administration would be reported immediately to the attending physician, and an incident report would be sent to nursing administration. Medications would be administered only upon the orders of physicians, dentists, or podiatrists who were members of the medical staff. There was no documented evidence of a facility policy on blood glucose monitoring and insulin administration. 1) Resident #27 was had [DIAGNOSES REDACTED]. The 12/2/2024 Minimum Data Set assessment documented the resident had intact cognition and received daily insulin injections. Physician orders [REDACTED]. - on 11/26/2024 [MEDICATION NAME] (blood thinner) 75 milligrams once a day by mouth; duloxetine (anti-depressant) 30 milligrams delayed released capsule once a day by mouth; [MEDICATION NAME] (cholesterol medication) 160 milligrams once a day by mouth; and levetiracetam [MEDICATION]) 500 milligrams twice a day by mouth. - on 12/7/2024 [MEDICATION NAME] (rapid-acting insulin) Injection Solution 100 units/milliliter per sliding scale subcutaneously before meals for [MEDICAL CONDITION]: if blood glucose level is 150 - 200 (milligrams/deciliter) = give 2 Units; 201 - 250 = give 4 Units; 251 - 300 give 6 Units; 301 - 350 = give 8 Units; 351 - 400 = give 10 Units; 401 - 450 = Notify provider if over 400. - on 12/12/2024 insulin [MEDICATION NAME] (long-acting insulin) 18 units subcutaneously every morning. The (MONTH) 2025 Medication Administration Record [REDACTED] - 8:00 AM [MEDICATION NAME] (generic name for [MEDICATION NAME]), duloxetine, [MEDICATION NAME], levetiracetam at 8:00 AM and 9:00PM - 9:00 AM insulin [MEDICATION NAME] at 9:00 AM - [MEDICATION NAME]at 7:30 AM, 12:00 PM, and 5:00 PM before meals inject as per sliding scale. During an observation on 1/17/2025 at 9:20 AM, Licensed Practical Nurse #24 performed a finger stick blood glucose on Resident #27 with a result of 326 milligrams/deciliter. The resident stated they ate a good breakfast just after 8:00 AM (approximately 90 minutes prior to the blood glucose test). Licensed Practical Nurse #24 prepared the following medications: [REDACTED]. Licensed Practical Nurse #24 prepared the [MEDICATION NAME] insulin, dialed the pen to 18 units and did not prime (remove air bubbles) the pen. Once preparation was completed at 9:38 AM, they asked a coworker to get the supervisor. At 9:45 AM Registered Nurse Educator arrived and was asked to check that the 8 units of [MEDICATION NAME]was drawn up correctly. Registered Nurse Educator approved the insulin dosing and Licensed Practical Nurse #24 entered the resident's room. Licensed Practical Nurse #24 proceeded to administer medications and the [MEDICATION NAME] and [MEDICATION NAME] insulins to the resident. The (MONTH) 2025 Medication Administration Record [REDACTED]. [MEDICATION NAME], duloxetine, [MEDICATION NAME], and levetiracetam were all signed as administered at 8:00 AM by Licensed Practical Nurse # 24. The resident's weight and vitals summary documented Licensed Practical Nurse #24 entered a blood sugar of 326 on 1/17/2025 at 9:54 AM. During an interview on 1/17/2025 at 10:00 AM, Licensed Practical Nurse #24 stated the [MEDICATION NAME]was due at 8:00 AM and the dose was based on the sliding scale and blood glucose results. After referring to the Medication Administration Record, [REDACTED]. Glucose levels should be done before meals to provide compensation for the food the resident would eat and would have enough insulin to continue throughout the day. If they checked the glucose level before they ate the result would have been different and likely lower. A lower result could have affected the amount of insulin that was needed. The next glucose check was due at 12:00 PM before lunch. If insulin doses were too close together it could cause [DIAGNOSES REDACTED] (low blood glucose). Licensed Practical Nurse #24 stated they were behind on their medication pass and the facility did not tell me what they were supposed to do. They stated insulin pens should be primed before dialing up the dose, but they did not do so with Resident # 27. If the pen was not primed, the resident would get less insulin than what was prescribed which could affect their blood sugar. During an interview on 1/23/2025 at 5:06 PM, Registered Nurse Educator stated they did not question Resident #27's insulin being administered at 9:45 AM on 1/17/2025 as there were new insulins that could be given at all times of the day. If a nurse was unable to get a blood glucose reading before the resident ate it should be reported as the sliding scale insulin would not apply. It should be reported to medical who would then direct the nurse what to do. During an interview on 1/23/2025 at 1:22 PM, Licensed Practical Nurse Manager #15 stated medications could be administered as early as an hour before and as late as an hour after the scheduled time. If a nurse was running late with medication administration, they should report, and the doctor should be contacted for further instructions. Blood glucose checks were done before breakfast by the day shift. It was important they were done before breakfast because if the resident ate first, it could skew the results. If the resident already ate before the nurse was able to obtain a blood glucose, they expected the nurse to report to them and not medicate based on that blood glucose result. Insulin should not be given two hours late as it could impact subsequent blood glucose readings. Resident # 27 was an insulin dependent diabetic and on sliding scale insulin before meals. Their morning insulin and blood glucose check were due at 7:30 AM. Checking blood glucose and administering insulin at 9:45 AM was not acceptable. They should have been notified to determine how to proceed but did recall anyone reporting to them on 1/17/ 2025. 2) Resident #110 had a [DIAGNOSES REDACTED]. The 12/26/2024 Minimum Data Set assessment documented the resident had intact cognition, required substantial assistance with most activities of daily living, and had a feeding tube. The 1/10/2025 physician orders [REDACTED]. - Eliquis 5 milligrams (a blood thinner) via percutaneous endoscopic gastrostomy tube (a feeding tube) twice a day - lacosamide oral solution 20 milliliters (an anti-[MEDICAL CONDITION] medication) via percutaneous endoscopic gastrostomy tube twice a day - [MEDICATION NAME] 25 milligrams (cardiac medication) via percutaneous endoscopic gastrostomy tube every 6 hours - [MEDICATION NAME] 20 milligrams (an antacid) via percutaneous endoscopic gastrostomy tube twice a day The (MONTH) 2025 Medication Administration Record [REDACTED] | Plan of Correction: ApprovedMarch 4, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Residents identified as #27 and #110 medication errors were identified and discussed with the Medical Director. LPN # 24's agency was notified of errors. LPN has not returned to the facility. LPN #10 was provided education on correct medication administration. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken Medication administration observations will be completed on all diabetic residents receiving insulin. Medication documentation audit will be reviewed to identify late medication administration. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Medication administration education and post test will be completed by all licensed nurses. Medication administration observation audit will be completed. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Medication administration reports will be reviewed daily for two weeks. A random daily report weekly will be completed for three months. Further audits will be conducted dependent on results of observations and audits completed. The date for correction and the title of the person responsible for correction of each deficiency Nurse Educator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated (NY 013) surveys conducted 1/20/2025-1/24/2025, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 1 of 1 resident (Resident #371) reviewed. Specifically, Resident #371 was care planned for 2-person assistance with a mechanical lift for transfers and Certified Nurse Aide #29 transferred the resident alone resulting in the resident nearly falling. The resident was not assessed by a qualified professional following notification of the care plan violation and was subsequently found with skin tears to both legs. Findings included: The facility policy, Resident Incident/Accident Documentation within Electronic Medical Record revised 7/25/2024, documented all incidents that involved resident care would be investigated and documented on the Incident Documentation Tool and enabled the facility to evaluate care given to residents, to assist in the prevention of incidents, and evaluate the intervention given in the event of an incident. An incident was an occurrence not consistent with the routine operation of the facility or routine care of a resident. Reports were completed by licensed practical nurses and registered nurses. The nursing supervisor or designee would immediately notify the Administrator or designee of statements that physical abuse, mistreatment, or neglect has occurred, if a physical condition, like a bruise, was inconsistent with the history or course of treatment of [REDACTED]. Resident #371 had [DIAGNOSES REDACTED]. The 8/7/2025 Minimum Data Set assessment documented the resident was cognitively intact but had periods of altered consciousness, had no behavioral symptoms, and required moderate assistance to dependence for most activities of daily living. The 7/31/2024 Comprehensive Care Plan documented the resident had an activities of daily living self-care performance deficit related to musculoskeletal impairment. Interventions included the resident was non-ambulatory, was dependent for transfers with two-person assistance and a mechanical lift, required moderate assistance of two people for lying to sitting at the edge of the bed, and required moderate assistance for rolling left to right. Staff statements completed on 9/7/2024 documented: -Licensed Practical Nurse #30 stated Certified Nurse Aide #29 approached them and stated they were leaving at the end of tray pass as they had attempted to transfer a resident to get them up for dinner, the resident was combative, and the resident was almost dropped to the floor. They attempted to gain help by turning on the call light and then pulling the call light from the wall to trigger the emergency light, but no one came to assist them. The Manager on Duty was notified and Licensed Practical Nurse #30 was asked to obtain statements from the other staff on the floor. Licensed Practical Nurse #30 determined the resident was a mechanical lift with assistance of 2, not a one-person transfer. - Certified Nurse Aide #33 noticed Resident #371 was not up for the dinner meal. Certified Nurse Aide #29 offered to go get the resident for the meal. Certified Nurse Aide #33 stated they thought the resident was a one-person transfer. Certified Nurse Aide #29 declined assistance to get the resident up. Certified Nurse Aide #29 was upset no one came to assist them and stated the resident pulled Certified Nurse Aide #29 down and the resident was almost on the floor. - Certified Nurse Aide #28 stated they were going to go get Resident #371 up for dinner and went to look at the list (for transfer status) and saw Certified Nurse Aide #29 at the desk then go down the hall. They asked Certified Nurse Aide #29 if they needed assistance and was told they did not. Approximately 5 to 10 minutes later, Certified Nurse Aide #29 went into the dining room asking where everyone was, they were calling for help because Resident #371 was sitting on the aide's leg. There was no documented evidence the resident was assessed by a qualified professional following the reported care plan violation with the transfer. The 9/8/2024 at 3:50 PM Licensed Practical Nurse #27 Incident note for a skin impairment documented. A bruise on the right shin and three skin tears on the left shin were found on 9/8/2024 at 10:20 AM while the resident was lying in bed. The origin of the skin tears and bruise were unknown. The skin tears required butterfly bandages and were left open to air. The provider and the resident's family were notified. The 9/8/2024 at 11:21 AM Investigation report prepared by Licensed Practical Nurse #39 documented: - on 9/8/2024 the resident was found in bed with four skin tears measuring 5. 0 by 0. 7 centimeters, 1. 0 by 1. 0 centimeters, 0. 5 by 0. 5 centimeters, and 1. 0 by 0. 6 centimeters on the left lower extremity, and a bruise measuring 5. 0 by 1. 5 centimeters on the right leg. - The resident was unable to give a description of what happened and was alert and orientated only to person. - The were no predisposing environmental or situational factors. The resident had impaired memory, impaired vision, poor safety awareness, and had a current acute condition. The 9/8/2024 investigation summary documented: - It was undetermined when the skin tears and bruise occurred, and they were discovered during morning care. - Licensed Practical Nurse #27 and Licensed Practical Nurse #28 were interviewed. They reported the skin tears and bruising were not present on 9/7/2024 in the morning and were present on 9/8/2024, during morning care. Licensed Practical Nurse #27 noted the skin tears were not present when they saw the resident's legs for a treatment on 9/7/2024 at 4:00 PM (before the inappropriate transfer occurred). - The resident was combative at times, they had poor intake of food and water, they were a mechanical lift transfer but there was one known incident of an attempt of a one person transfer 9/7/2024 in the evening with no noted skin tears. The undated Investigation Conclusion signed by the Director of Nursing documented the care plan violation was the first incident and documented Certified Nurse Aide #29 was suspended for three days and was re-educated on checking the Kardex for each resident and making sure to follow it. There were planned and scheduled (MONTH) in-services for bed mobility, safe transfers, and mechanical lift training. They were unable to determine the cause of the skin tears. The resident was noted to be combative with care and that could have been the cause of the skin tear. The resident had a history of [REDACTED]. There was no documented evidence the facility addressed the lack of assessment by a qualified professional on 9/7/2024 for possible injury following the transfer by one staff. During a telephone interview on 1/21/2025 at 1:57 PM, Certified Nurse Aide #29 stated they were serving dinner trays in the dining room when they noticed Resident #371 was not in the dining room. They offered to go get the resident and was informed by Certified Nurse Aide #33 the resident was a one-person transfer. They woke Resident #371 up, got them turned to the side of the bed with the wheelchair next to the bed, and attempted to stand the resident with a gait belt. Resident #371 started to be combative, was not bearing weight, and almost slid off the bed due to being mid-transfer. Certified Nurse Aide #29 stated they had to put their leg in-between the resident's legs and scoot the resident back onto the bed. When the aide went to the nursing station, they were informed the resident was a mechanical lift, not a one-person assist. One of the nurses, they were unsure whom went to assist with getting the resident up. The nurse did a full body check and there were no injuries | Plan of Correction: ApprovedMarch 4, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident identified as #371 has since been discharged from the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken Reviewed and investigated the previous 30 days of accidents/incidents regarding skin impairments. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Educate administrative nursing staff on the Recognizing and reporting elder abuse/neglect criteria policy. As well as education on conducting thorough investigations. The policy addresses completion of an assessment of the resident for injuries and has been updated to include documentation of the assessment in the accident/incident report. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice All skin impairments of unknown origin will be reviewed by the Director of Quality Management and reported on during QAPI monthly for three months and quarterly thereafter. The date for correction and the title of the person responsible for correction of each deficiency Administrator. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice 1 of 1 resident (Resident #49) reviewed. Specifically, Resident #49 was administered 14 doses of expired levetiracetam ([MEDICAL CONDITION] medication) from 1/10/2025 to 1/17/ 2025. Findings include: The facility policy, Medication Administration, revised 9/2019 documented the individual administering the medication should verify the medication selected for administration was the correct medications based on the medication order and the medication label. The individual administering a medication should be aware of the following information concerning each medication before administration: the route and frequency of administration, appropriate timing of medication administration, normal dosage and maximum dosage, and the expiration date had not been exceeded. Errors in administration of medications would be reported immediately to the attending physician and an incident report would be sent to nursing administration. Resident #49 had [DIAGNOSES REDACTED]. The 12/19/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment and a history of a [MEDICAL CONDITION] disorder. An 8/8/2023 physician order [REDACTED]. During the Unit 3 medication cart inspection on 1/17/2025 at 12:34 PM with Licensed Practical Nurse #31, there was a medication card (blister pack) for Resident #49 with levetiracetam 250 milligram tablets and an expiration date of 12/30/ 2024. The medication was dispensed on 8/21/2024 and had 14 tablets missing from the medication card. Licensed Practical Nurse #31 stated they did not realize the medication was expired and administered the levetiracetam to Resident #49 that morning. There were no additional blister packs of levetiracetam 250 milligram tablets in the medication cart. The blister pack had space for 30 tablets. The spot where the second dose of the medication was removed was initialed and dated 1/11/ 2025. There were 16 tablets remaining in the blister pack. The 1/2025 Medication Administration Record [REDACTED] - on 1/10/2025 at 8:00 PM by Licensed Practical Nurse #31 - on 1/11/2025 at 8:00 AM by Registered Nurse #39; at 8:00 PM by Licensed Practical Nurse # 30. - on 1/12/2025 at 8:00 AM by Registered Nurse #39; at 8:00 PM by Licensed Practical Nurse # 40. - on 1/13/2025 at 8:00 AM and 8:00 PM by Registered Nurse # 39. - on 1/14/2025 at 8:00 AM and 8:00 PM by Registered Nurse # 39. - on 1/15/2025 at 8:00 by Licensed Practical Nurse #10; at 8:00 PM by Licensed Practical Nurse # 2. - on 1/16/2025 at 8:00 by Licensed Practical Nurse #31; at 8:00 PM by Licensed Practical Nurse # 30. - on 1/17/2025 at 8:00 AM by Licensed Practical Nurse # 31. Nursing progress notes dated 1/10/2025-1/16/2025 did not document [MEDICAL CONDITION] activity for Resident # 49. During an interview on 1/23/2025 at 4:27 PM, Licensed Practical Nurse #31 stated medication was delivered to the facility twice a day. The medication cards were not checked for expiration as often as they should, and they did not usually check the cards until more medication arrived. If medication was noted as expired, they should replace it. Medications should not be administered past their expiration date because they could lose their potency and were not as effective. During an interview on 1/23/2025 at 4:35 PM, Licensed Practical Nurse Unit Manager #32 stated medications were delivered to the facility twice a day and the expiration dates were checked weekly on all medication cards. If a medication was expired the nurse should have removed it from the medication cart, reordered the medication, and notified the Unit Manager. If an expired medication was given to a resident the physician should have been notified and there was no documented evidence the physician was made aware that Resident #49 was administered expired levetiracetam. They stated expired medications should not have been administered to Resident #49 because the effectiveness of the medication was not accurate, and they were unsure what the medication could do to the resident. During an interview on 1/23/2025 at 9:21 AM, the Director of Nursing stated they were unsure how often the nurses checked medication expiration dates. They were working with the nurses on not over ordering medications and they did not think the nurses were looking at expiration dates. They stated nurses should rotate the older medication cards to the front when new cards arrived at the facility. Resident #49 should not have received expired medications because the efficacy could have changed. During an interview on 1/24/2025 at 10:41 AM, Physician #7 stated they expected nurses to check expiration dates before they administered any medication. They wanted to be notified if a resident received expired medication. 10NYCRR 415. 12 | Plan of Correction: ApprovedFebruary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident identified as #49s [MEDICATION NAME] level will be checked. The expired medication was removed and the MD was notified. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The medication carts were all audited for expired medications and no further expired medications were found. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur All licensed nurses will receive education on the medication administration policy. An updated 11p-7a nursing checklist will include removal of all expired medications from the medication cart nightly. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Medication carts will be audited weekly for three months, monthly for three months and quarterly for six months. Audits will be reported to QAPI monthly. The date for correction and the title of the person responsible for correction of each deficiency Director of Quality Management |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on interviews and record review during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that views, grievances, or recommendations voiced by residents during Resident Council group meetings were considered or acted upon and responded to with a rationale for 10 of 10 anonymous residents present at the resident group meeting. Specifically, 10 of 10 anonymous residents present at the resident group meeting stated they did not receive responses to topics or concerns addressed in prior meetings. Additionally, there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided to the residents. Findings include: The facility policy, Resident Council, revised 3/18/2024, documented the resident council would provide a platform for residents to voice their concerns, provide feedback, and actively participate in decision-making processes that would directly impact their living conditions and experiences within the facility. The resident council would serve as a liaison between residents and facility administration addressing concerns or complaints regarding facility operations, policies, and resident experiences. The council appointed liaison would assist with documentation, relaying concerns to facility managers, ensuring facility follow through and would report back to the council as requested. The facility policy Resident Rights, revised 3/18/2024, documented the facility would establish a formal process for residents to file complaints or grievances. Residents would be provided with information on the procedure for addressing complaints and would have access to a designated individual or department to seek resolution. During a resident group meeting on 1/17/2025 at 9:54 AM, 10 anonymous residents stated the facility did not follow up, address, or resolve their concerns. They stated they did not receive any feedback from the facility about concerns regarding staff not responding timely to call lights, communication with unit staff, noise levels on the units during shift change and at night, and one resident stopped attending because they felt like it was useless. Resident Council meeting minutes documented: - on 8/2/2024, old business noted, calls bells were not being answered timely, residents were not receiving their meds because they were unavailable, noise levels at night were awful especially during 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. New concerns were raised about staff playing music while performing care and passing meal trays. - on 9/6/2024, old business noted, call bells not being answered timely, medications not available, Unit 2 staff were still noisy on 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts, agency nurses forgot to give medications, and staff played music when performing care and passing meal trays. New concerns were raised about staff using offensive language. - on 10/21/2024, old business noted, call bells not being answered timely, medications were still not in the facility, Unit 2 staff was still noisy, staff played music when performing care and passing meal trays, and staff were still using offensive language. New concerns were raised about residents taking food from other trays, and cell phones being used by aides in resident rooms. The residents felt like they were attending resident council meetings and complaining but nothing was being done about it. - on 11/1/2024, old business noted, call bells not being answered timely, medications were given late, residents and staff were loud, staff were still using offensive language, and music was played on staff cellphones. New concerns were raised about cellphone usage at the nursing station, residents were getting up late for breakfast, items were stolen from resident rooms, and residents were not being assisted to bed timely. - on 12/6/2024, old business noted, residents not woken up for breakfast, items were stolen from resident rooms, personal cellphone usage at the nursing station, and not being assisted to be timely. New concerns were raised about loud staff, staff swearing and using inappropriate language, staff were not being truthful, staff were taking too many breaks at once, music was played on staff cellphones, staff were wearing ear buds while providing care, and residents were assisted to bed too early/late. The residents wanted to see compliance with their concerns and not just on paper. Resident Council staff responses documented: - in 8/2024, the Food Service department noted nursing was responsible for checking all items on resident trays and they would monitor dietary staff to ensure they did not have their phones out during meal service, and they believed it was a Director of Nursing issue. There were no other documented staff responses related to resident's voiced concerns. - in 9/2024, the Nursing Department noted they would start monthly staff meetings and include break education, education to staff on passing medications in the dining room and using basins for hygiene and hiring and training new staff to allow for timely care. The dietary department noted residents would need to notify nursing if they had a missing item on their tray and nursing should check all trays prior to the tray going to the resident. - in 10/2024, the Food Service department noted residents who took food off trays should be reported to the nursing staff who oversaw the meal service. Once meals were delivered to residents it was nursing staff who supervised meal consumption. There were no other documented staff responses to the resident's voiced concerns. - in 11/2024, there were no documented staff responses to the resident's voiced concerns. - in 12/2024, the nursing department noted all issues were addressed in staff meetings. During an interview on 1/24/2025 at 8:41 AM Recreation Leader #37 stated they ran resident council meetings until December 2024. During the Resident Council meetings, they went around the table and asked the residents what their issues were so they could let other departments know. They documented the specific issues and delivered them to each department. A response sheet was filled out and returned with the plans to fix the problems. In the next resident council meeting they would go over old business and how it was addressed before they moved on to new concerns. They were unsure why the old business and new business had a lot of the same concerns with no resolutions. They were not the one who typed up the minutes or held onto the staff response sheets. Residents expressed their concerns were not addressed and they were not seeing changes. They stated it was important to address resident council concerns because the facility was the residents' home, and it was their job to make sure residents were taken care. During an interview on 1/24/2025 at 11:30 AM, Activities Director #36 stated they started at the facility in the middle of November, and they reviewed the old Resident Council minutes. The minutes seemed to be all over the place with no structure. They noticed reoccurring issues that were not resolved. They constructed a new agenda since they took over Resident Council and they thought the resident's concerns were now being addressed. The resident's wanted to see things done and not just on paper. Activities Director #36 stated they reviewed the minutes in their monthly Quality Assurance and Performance Improvement meetings. They thought since bring the issues to the meeting, there was more of a response from other departments. During an interview on 1/24/2025 at 12:01 PM, the Administrator stated they were not involved with Resident Council, but they reviewed the monthly minutes. They tried to follow up with the residents' concerns within a week or by the next meeting. Facility response sheets were kept with the minutes and were brought back to the Resident Council meetings to address concerns. They saw repeated concerns on the monthly minutes, but they had a new Activities Director who made corrections to the resident council. They thought outcomes were being communicat | Plan of Correction: ApprovedFebruary 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice A memo addressing cell phone use, playing music, wearing ear buds and inappropriate language will be sent to all staff directly through the employee payroll system. All old business noted on the latest resident council minutes will be addressed and responded to accordingly. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken A survey will be conducted to all residents and/or responsible parties regarding concerns, potential grievances or complaints. Each topic will be addressed and brought to the appropriate department head to respond. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Education was completed to all Department head level staff for addressing and responding to resident council concerns. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Director of Therapeutic Recreation will report compliance at QAPI monthly for 6 months and quarterly thereafter. The date for correction and the title of the person responsible for correction of each deficiency Director of Therapeutic Recreation |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review conducted during the Life Safety Code survey 1/16/2025 to 1/24/2025, the facility did not ensure cooking facilities were maintained in accordance with National Fire Protection Association (NFPA) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations for 1 of 1 kitchen hood fire suppression systems within the main kitchen. Specifically, 2 of 3 kitchen staff interviewed were not aware of how to activate the kitchen hood fire suppression system in the main kitchen. Findings include: During an interview on 1/16/2024 at 2:30 PM, Cook #43 stated in the event of a fire on the cookline they would get a fire extinguisher, pull the fire alarm, and they thought there was an emergency button, but they were not sure where that was located. During an interview on 1/16/2024 at 2:30 PM, Dietary Supervisor #46 stated in the event of a fire on the cookline they would get a fire extinguisher, pull the fire alarm, and try to get staff out. They were not aware of the kitchen fire suppression system. During an interview on 1/17/2024 at 3:47 PM, the Director of Facility Services stated the kitchen staff were trained on the kitchen fire suppression system and the use of the K-type fire extinguisher annually. All dietary staff should have been familiar with the fire suppression system. 2012 NFPA 101 19. 3. 2. 5. 5, 19. 3. 5. 3, 9. 2. 3, table 9. 7. 3. 1 2011 NFPA 96 10. 2. 6, 10. 5. 7, 11. 2. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Cooking Facilities ÔÇ£ Staff Training on the Kitchen Fire Suppression system) The Facility Services Director will train all the Kitchen staff How to properly use the Kitchen Fire Suppression system and where the pull switch is located to operate it. The Facility Services Director or a properly trained designee will train all dietary staff, nursing supervisors, maintenance staff and custodial staff on how to properly use the Kitchen Fire Suppression system and where the pull switch is to operate it. This will also include all new hired employees within the identified departments. The Facility Services Director or properly trained designee will conduct periodic audits to ensure staff knowledge of kitchen fire suppression system and report results to QAPI. The audits will be monitored and reported to the QAPI committee on a quarterly basis for one year and annual thereafter. The deficiency will be corrected no later than 3/25/ 25. The Facility Services Director will be responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey conducted 1/16/2025 to 1/24/2025, the facility did not ensure corridor doors were properly maintained for 1 location. Specifically, the server room door did not close and latch properly. Findings include: During an observation on 1/16/2025 at 1:11 PM, the server room door did not close and latch properly when tested . During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated they were aware the corridor doors were required to close and latch, but not aware the server room door was not latching properly. 2012 NFPA 101 19. 3. 6. 3, 19. 3. 6. 3. 4 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Corridor Doors) The Corridor door to the server room has been repaired. The door was repaired on: 1/24/25 The Facility Services Director or designee will conduct a facility wide audit of all corridor doors throughout the building. Any deficiencies found will be corrected in a timely manner. The Facility services Director or designee will conduct an audit for all corridor doors throughout the building on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than: 3/25/ 25. The Facility services Director will be responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 1/16/2025 to 1/24/2025, the facility did not ensure electrical installations were properly maintained and installed for 1 location. Specifically, the sensory room had power strips in use as a substitute for fixed wiring. Findings include: During an observation on 1/16/2025 at 3:06 PM, the sensory room had (4) power strips mounted to the walls for various lights. The power strips were a substitute for fixed wiring. During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated they were not aware the power strips were not allowed for that use, and they could add outlets as needed. 2012 NFPA 99: 10. 2. 3. 6, 10. 2. 4 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Power strips mounted to the wall in sensory room) The power strips will be removed from the wall in the sensory room. The Facility services Director or designee will conduct a facility wide audit throughout the facility. This audit will be added to the PCREE and non-PCREE audit. Any deficiencies found will be corrected The Facility services Director or designee will conduct a facility wide audit throughout the facility. This audit will be added to the PCREE and non-PCREE audit. Any deficiencies found will be corrected. This audit will be conducted on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than: 3/25/ 25. The Facility Services Director will be responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on record review, observation and interview during the Life Safety Code recertification survey conducted 1/16/2025 to 1/24/2025, the facility did not ensure exit signs were posted in accordance with National Fire Protection Association (NFPA) 101 for two locations. Specifically, the upper courtyard doors were not properly labeled. Findings include: During an observation on 1/16/2025 at 12:58 PM, the double doors to the upper courtyard were not labeled as an exit, or No Exit. The doors could be mistaken for an exit. During an observation on 1/16/2025 at 1:00 PM, the single door from the second-floor lounge area to the upper courtyard was not labeled No Exit. The door is not identified as an exit or not an exit but could be mistaken for an exit. During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated the doors should have been labeled no exit. They stated it was important those doors were properly labeled for the safe egress of residents and staff. 2012 NFPA 101: 19. 2. 10. 1, 7. 10 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Exit Signage) The Facility Services Director has installed the proper signage to read (No Exit) on the following doors: The double doors to the upper courtyard, second-floor lounge, and 3 east middle hall door to the roof. The Facility Services Director or designee will conduct a Facility wide audit of all (No Exit) doors throughout the facility to ensure that there are no other non-exit doors that are out of compliance and if there are any other doors found to be deficient they will be corrected in a timely manner. The Facility Services Director or designee will conduct a Facility wide audit of all Non Exit doors throughout the facility on a quarterly basis to ensure that signage remains on the doors. The audits will be monitored and reported the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/ 25. The Facility Services will be responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on record review, observation and interview during the Life Safety Code recertification survey conducted 1/16/2025 to 1/24/2025, the facility did not ensure that hazardous areas were maintained. Specifically, the housekeeping office was converted to resident storage, but the room was not properly rated as a hazardous storage room. Findings include: During an observation on 1/16/2025 at 12:58 PM, the housekeeping office had been converted to a resident storage room. The room was approximately 80 square feet, but the door assembly was not fire rated and not self-closing. During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated they were not sure when the office was converted, but they were aware hazardous storage rooms were required to be properly rated. 2012 NFPA 101 19. 3. 2. 1, 19. 3. 2. 1. 3, 4. 6. 11 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 ( Converted Housekeeping office to storage) The Facility Services Director or designee will remove the temporary stored items from the Housekeeping office and returning it to be an office. The Facility Services Director or designee will conduct a facility wide audit to ensure there are no other storage areas in the building that are out of compliance and if any are found to be out of compliance the storage area will be corrected in a timely manner to meet the standard. The Facility Services Director or designee will conduct an audit on a quarterly basis to inspect all storage areas in the building to ensure all other storage rooms remain in compliance with the standard. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/ 25. The Facility Services Director will be responsible for this plan of correction. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey conducted 1/16/2025 to 1/24/2025, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system as required by CMS regulation 483. 90(a) physical environment, for multiple locations. Specifically, the facility had mixed sprinkler coverage in stairwells and the boiler room; and lacked sprinkler coverage in an outdoor storage location under the building's roof. Finding include: During an observation on 1/16/2025 at 12:53 PM, the stairwell on 2 (Northeast side by double door side exit) contained both standard and quick response sprinklers. During an observation on 1/16/2025 at 1:23 PM, the stairwell by the kitchen contained standard and quick response sprinklers. During an observation on 1/16/2025 at 1:47 PM, two propane tanks and a gas grill were stored under the overhang of the building's roof. During an observation on 1/16/2025 at 2:52 PM, the boiler room contained standard response and 1 quick response sprinkler (located beneath duct work by a side exit door). During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated they were not aware of the mixed sprinklers in the facility, but they were aware of the regulation. They stated the propane tanks did not need to be stored there, and they would be moved to a proper storage location. 2012 NFPA 101: 19. 3. 5, 19. 3. 5. 1, 9. 7, 9. 7. 1. 1 2011 NFPA 13 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Sprinkler System- Installation) The Facility Services Director is currently in the process of scheduling to have the incorrect sprinklers replaced in the following areas: Stairwell on 2nd floor North East side by double doors that had one standard response head that should have been quick response, the stairwell by kitchen that one standard response head that should have been quick response, 1st floor Boiler room/ Mechanical room that had one standard response head that should have been quick response.(two Propane tanks stored under exterior overhang): Both tanks have been removed. Missing spare sprinkler heads) The Facility Services Director is in the process of adding the following spare sprinkler heads: Green vertical spare heads, Blue pendant standard heads, The Facility Services Director or designee will conduct a facility wide audit of all compartments with sprinklers. This will include auditing the exterior of the building and in addition the spare sprinklers cabinets. The Facility Services Director or designee on a quarterly basis will conduct a facility wide audit of all compartments with sprinklers, this will include auditing the exterior of the building and in addition the spare sprinkler cabinets. Any deficiencies found will be corrected in a timely manner. The audits will be monitored and reported to the QAPI committee on a quarterly basis The deficiency will be corrected no later than 3/25/ 25. The Facility Services Director will be responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review conducted during the Life Safety Code survey 1/16/2025 to 1/24/2025, the facility did not ensure 1 of 1 automatic sprinkler systems were maintained. Specifically, the facility was missing spare sprinklers. Findings include: Missing spare sprinklers: During an observation on 1/16/2025 at 12:16 PM, the boiler room had green vertical standard response sprinkler heads. During an observation on 1/16/2025 at 1:09 PM, the laundry room had green vertical standard response sprinkler heads. During an observation on 1/16/2025 at 1:21 PM, the server room had blue pendant standard response sprinkler heads. During an observation on 1/16/2025 at 2:50 PM, the spare sprinklers were reviewed, only quick response sprinklers were available, no standard response spares were present. The facility was required to have a spare for each type and temperature rating present in the facility. During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated they were aware they were required to have a spare sprinkler for each type in the facility, but not aware their supply of spares was lacking standard response sprinklers. 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 5 2011 NFPA 25 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Missing Spare Sprinklers) The Facility Services Director is currently in the process of ordering the following spare sprinkler heads and will be added to the spare sprinkler cabinet: Green vertical standard heads, Blue vertical standard heads, Red vertical standard heads, Green pendant standard heads, Blue pendant standard heads, Red pendant standard heads. The Facility Services Director will conduct an audit of all the spare sprinkler heads stored in the spare sprinkler cabinets to ensure there are no other spare heads missing from the cabinets. If there are any spare heads missing they will be replaced in a timely manner. The Facility services Director or designee will conduct an audit of the spare heads on a quarterly basis. The audit will be included in the Sprinkler audit form. Any deficiencies found will be corrected in a timely manner. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/ 25. The Facility Services Director will be responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey conducted 1/16/2025 to 1/24/2025, the facility did not ensure electrical equipment had approved wiring and electrical outlets in accordance with NFPA 70, 2011 Edition for 2 rooms. Specifically, the physical therapy room and the admissions office had outlets that were not protected from water with a proper ground fault circuit interrupter and power strips located on the floor. Findings include: During an observation on 1/16/2025 at 11:57 AM, the physical therapy room had (2) [MEDICATION NAME] plugged into regular outlets that were not protected by a ground fault circuit interrupter. During an observation on 1/16/2025 at 12:28 PM, the Admissions Office had a power strip located directly on the floor, not protected from water when the floor would have been mopped. During an interview on 1/24/2024 at 3:23 PM, the Director of Facility Services stated they were aware that outlets had to be protected from water, but they did not realize the [MEDICATION NAME] and power strip on the floor were not properly protected. 2012 NFPA 101: 19. 5. 1, 9. 1. 2 2011 NFPA 70 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 7, 2025 (Physical Therapy room and Admissions office) The standard electrical outlets will be replaced with a Ground fault circuit interrupter that will meet NFPA 70 standards the power strip in the Admissions office will be mounted to the wall 12?Ø off the floor. The Facility Services Director will conduct a Facility wide audit of all electrical outlets throughout the building to ensure that no electrical devices that contain water or could come in contact with water or liquid. If there are any deficiencies found the deficiency will be corrected in a timely manner. The Facility Services Director will conduct a Facility wide audit of all electrical outlets throughout the building to ensure that no electrical devices that contain water or could come in contact with water or liquid. If there are any deficiencies found the deficiency will be corrected in a timely manner. This will be done on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will corrected no later than: 3/25/ 25. The Facility Services Director will be responsible for this plan of correction. |